Executes enterprise utilization management strategy aligned with organizational and regulatory requirements
Oversees operations including prior authorization, medical necessity review, and concurrent review processes
Ensures compliance with CMS, payer, and state regulatory requirements
Identifies and mitigates audit, compliance, and reimbursement risks
Monitors performance metrics including denial trends and utilization efficiency
Drives performance improvement initiatives based on data analysis
Collaborates with clinical, case management, and revenue cycle teams to improve documentation and reduce denials
Supports implementation and optimization of utilization management technologies and workflows
Leads and develops managers and operational leaders
Supports succession planning and organizational capability development
May be required to perform other job-related duties as requested.

Bachelor’s degree or equivalent combination of education and experience
Current RN license
10+ years of relevant experience including advanced knowledge of utilization management and healthcare reimbursement
5+ years of people leadership experience
Strong executive presence with the ability to project confidence, credibility and authority; able to remain calm & show decisiveness under pressure
Exhibits strong strategic and analytical skills with the ability to drive operational improvements
Ability to build and maintain relationships with key internal and external stakeholders
Ability to effectively lead diverse teams and influence change management in a complex healthcare operations environment
Effective communication skills with ability to clearly and succinctly convey information and ideas
Demonstrated advanced usage of AI, success in translating AI into Business outcomes, and the ability to move teams from experimentation to scale.

AVP, Utilization Management

Key skills